目录
2018年第4期(发布时间: Jul 15, 2019 发布者:张燕舞)  下载: 2018年第4期.doc       全选  导出
1   2018-07-16 16:19:22.08 运动揭示了射血分数保留心力衰竭和肺血管疾病中不同的病理生理特征 (点击量:0)

目标:肺动脉高压(PH)和肺血管疾病(PVD)是常见的,并与射血分数保留心力衰竭(HFpEF)的不良后果相关。关于PVD对运动不耐受的病理生理学的影响知之甚少。

方法和结果:射血分数保留心力衰竭患者(n = 161)并且静息时肺毛细血管楔压升高(≥15mmHg)的被分为三组:非PH-HFpEF(n = 21); PH但没有PVD(孤立性毛细血管后肺动脉高压,IpcPH; n = 95);和PH与PVD(毛细血管前及毛细血管后复合肺动脉高压,CpcPH; n = 45)。静息时,与其他所有组相比,CpcPH-HFpEF患者出现更多右心室(RV)功能障碍和更低的肺动脉(PA)顺应性。虽然右心房压(RAP)和左心室透壁压(LVTMP)在静息时有或没有PH或PVD的HFpEF中相似,但CpcPH-HFpEF患者在运动期间表现出更大的RAP增加、增强的心室间相互依赖和LVTMP的反常减少,这些与所有其他组存在差异(P <0.05)。较低的PA顺应性与运动时RAP的较大增加相关。在运动过程中,CpcPH-HFpEF患者表现出无法增强心输出量、前向搏动量减少、RV收缩性能的迟钝增加以及伴随有氧能力显著限制的变化。

结论:PVD射血分数保留心力衰竭患者在运动期间表现出独特的血流动力学限制,限制了有氧能力包括由于右心充血过度导致的LV预负荷受损和RV收缩储备减弱。针对这种独特病理生理学的干预措施需要对患有HFpEF和PVD的患者进行检测。

2   2018-05-22 10:37:53.827 非心脏手术后高敏感性心肌肌钙蛋白升高 (点击量:0)

许多接受非心脏手术的患者,尤其是那些心血管疾病风险增加的患者,发现术后高敏感性心肌肌钙蛋白(hs-cTn)升高。 其中大多数没有心肌梗塞的临床表现。 在一项前瞻性研究中,约2000名心血管风险增加的患者(超过2500例手术)在手术前后测量了hs-cTnT。 无论心肌梗死的临床表现如何,hs-cTnT在手术中有16%发生增加,并且与30天和1年的死亡率增加相关。 我们建议在高心血管风险的患者中进行围手术期hs-cTn检测,以筛查心肌损伤和心电图监测,影像学检查或阿司匹林或他汀类药物治疗的需求。

BACKGROUND Perioperative myocardial injury (PMI) seems to be a contributor to mortality after noncardiac surgery. Because the vast majority of PMIs are asymptomatic, PMI usually is missed in the absence of systematic screening.

METHODS We performed a prospective diagnostic study enrolling consecutive patients undergoing noncardiac surgery who had a planned postoperative stay of≥24 hours and were considered at increased cardiovascular risk. All patients received a systematic screening using serial measurements of high-sensitivity cardiac troponin T in clinical routine. PMI was defined as an absolute high-sensitivity cardiac troponin T increase of≥14 ng/L from preoperative to postoperative measurements. Furthermore, mortality was compared among patients with PMI not fulfilling additional criteria (ischemic symptoms, new ECG changes, or imaging evidence of loss of viable myocardium) required for the diagnosis of spontaneous acute myocardial infarction versus those that did.

RESULTS From 2014 to 2015 we included 2018 consecutive patients undergoing 2546 surgeries. Patients had a median age of 74 years and 42% were women. PMI occurred after 397 of 2546 surgeries (16%; 95% confidence interval, 14%-17%) and was accompanied by typical chest pain in 24 of 397 patients (6%) and any ischemic symptoms in 72 of 397 (18%). Crude 30-day mortality was 8.9% (95% confidence interval [CI], 5.7-12.0) in patients with PMI versus 1.5% (95% CI, 0.9-2.0) in patients without PMI (P<0.001). Multivariable regression analysis showed an adjusted hazard ratio of 2.7 (95% CI, 1.5-4.8) for 30-day mortality. The difference was retained at 1 year with mortality rates of 22.5% (95% CI, 17.6-27.4) versus 9.3% (95% CI, 7.9-10.7). Thirty-day mortality was comparable among patients with PMI not fulfilling any other of the additional criteria required for spontaneous acute myocardial infarction (280/397, 71%) versus those with at least 1 additional criterion (10.4%; 95% CI, 6.7-15.7, versus 8.7%; 95% CI, 4.2-16.7;P=0.684).

CONCLUSIONS PMI is a common complication after noncardiac surgery and, despite early detection during routine clinical screening, is associated with substantial short- and long-term mortality. Mortality seems comparable in patients with PMI not fulfilling any other of the additional criteria required for spontaneous acute myocardial infarction versus those patients who do.

CLINICAL TRIAL REGISTRATION URL: https://www.clinicaltrials.gov. Unique identifier: NCT025735

3   2018-05-22 10:36:44.64 腹主动脉瘤的更新指南 (点击量:0)

2018年2月,美国血管外科学会(SVS)发布了关于腹主动脉瘤(AAA)患者护理的最新指南。 与先前指南的主要区别包括较长的超声监视小AAA的间隔时间,使用血管质量计划围手术期死亡风险评分来辅助选择性AAA的决策制定,并且当解剖学适合时,血管内而不是开放性AAA破裂修复,包括快速 如果急诊科能够在90分钟内完成手术干预,则转移至血管中心。 我们的建议与这些修订是一致的。

BACKGROUND Decision-making related to the care of patients with an abdominal aortic aneurysm (AAA) is complex. Aneurysms present with varying risks of rupture, and patient-specific factors influence anticipated life expectancy, operative risk, and need to intervene. Careful attention to the choice of operative strategy along with optimal treatment of medical comorbidities is critical to achieving excellent outcomes. Moreover, appropriate postoperative surveillance is necessary to minimize subsequent aneurysm-related death or morbidity.

METHODS The committee made specific practice recommendations using the Grading of Recommendations Assessment, Development, and Evaluation system. Three systematic reviews were conducted to support this guideline. Two focused on evaluating the best modalities and optimal frequency for surveillance after endovascular aneurysm repair (EVAR). A third focused on identifying the best available evidence on the diagnosis and management of AAA. Specific areas of focus included (1) general approach to the patient, (2) treatment of the patient with an AAA, (3) anesthetic considerations and perioperative management, (4) postoperative and long-term management, and (5) cost and economic considerations.

RESULTS Along with providing guidance regarding the management of patients throughout the continuum of care, we have revised a number of prior recommendations and addressed a number of new areas of significance. New guidelines are provided for the surveillance of patients with an AAA, including recommended surveillance imaging at 12-month intervals for patients with an AAA of 4.0 to 4.9 cm in diameter. We recommend endovascular repair as the preferred method of treatment for ruptured aneurysms. Incorporating knowledge gained through the Vascular Quality Initiative and other regional quality collaboratives, we suggest that the Vascular Quality Initiative mortality risk score be used for mutual decision-making with patients considering aneurysm repair. We also suggest that elective EVAR be limited to hospitals with a documented mortality and conversion rate to open surgical repair of 2% or less and that perform at least 10 EVAR cases each year. We also suggest that elective open aneurysm repair be limited to hospitals with a documented mortality of 5% or less and that perform at least 10 open aortic operations of any type each year. To encourage the development of effective systems of care that would lead to improved outcomes for those patients undergoing emergent repair, we suggest a door-to-intervention time of <90 minutes, based on a framework of 30-30-30 minutes, for the management of the patient with a ruptured aneurysm. We recommend treatment of type I and III endoleaks as well as of type II endoleaks with aneurysm expansion but recommend continued surveillance of type II endoleaks not associated with aneurysm expansion. Whereas antibiotic prophylaxis is recommended for patients with an aortic prosthesis before any dental procedure involving the manipulation of the gingival or periapical region of teeth or perforation of the oral mucosa, antibiotic prophylaxis is not recommended before respiratory tract procedures, gastrointestinal or genitourinary procedures, and dermatologic or musculoskeletal procedures unless the potential for infection exists or the patient is immunocompromised. Increased utilization of color duplex ultrasound is suggested for postoperative surveillance after EVAR in the absence of endoleak or aneurysm expansion.

CONCLUSIONS Important new recommendations are provided for the care of patients with an AAA, including suggestions to improve mutual decision-making between the treating physician and the patients and their families as well as a number of new strategies to enhance perioperative outcomes for patients undergoing elective and emergent repair. Areas of uncertainty are highlighted that would benefit from further investigation in addition to existing limitations in diagnostic tests, pharmacologic agents, intraoperative tools, and devices.

4   2018-05-22 10:35:04.037 氟喹诺酮类药物和主动脉瘤及其切除的风险 (点击量:0)

氟喹诺酮具有可能损害血管壁完整性的非抗微生物特性。 在瑞典进行的一项全国范围队列研究中,与使用阿莫西林相比,氟喹诺酮在治疗开始后60天内与主动脉瘤或夹层事件风险增加相关(每1000人年有1.2例与0.7例;绝对差值为每1例82例 百万次治疗发作),与先前研究中的发现一致。 我们认为,这项新研究不会导致修订2017年美国食品和药物管理局安全通信,指出对现有信息的审查不支持氟喹诺酮类药物引起主动脉瘤或剥离的报道。 如果存在关联,绝对风险很小,并且可能仅限于具有其他易感风险因素的个体。

OBJECTIVE To investigate whether oral fluoroquinolone use is associated with an increased risk of aortic aneurysm or dissection.

DESIGN Nationwide historical cohort study using linked register data on patient characteristics, filled prescriptions, and cases of aortic aneurysm or dissection.

SETTING Sweden, July 2006 to December 2013.

PARTICIPANTS 360 088 treatment episodes of fluoroquinolone use (78%ciprofloxacin) and propensity score matched comparator episodes of amoxicillin use (n=360 088).

MAIN OUTCOME MEASURES Cox regression was used to estimate hazard ratios for a first diagnosis of aortic aneurysm or dissection, defined as admission to hospital or emergency department for, or death due to, aortic aneurysm or dissection, within 60 days from start of treatment.

RESULTS Within the 60 day risk period, the rate of aortic aneurysm or dissection was 1.2 cases per 1000 person years among fluoroquinolone users and 0.7 cases per 1000 person years among amoxicillin users. Fluoroquinolone use was associated with an increased risk of aortic aneurysm or dissection (hazard ratio 1.66 (95% confidence interval 1.12 to 2.46)), with an estimated absolute difference of 82 (95% confidence interval 15 to 181) cases of aortic aneurysm or dissection by 60 days per 1 million treatment episodes. In a secondary analysis, the hazard ratio for the association with fluoroquinolone use was 1.90 (1.22 to 2.96) for aortic aneurysm and 0.93 (0.38 to 2.29) for aortic dissection.

CONCLUSIONS In a propensity score matched cohort, fluoroquinolone use was associated with an increased risk of aortic aneurysm or dissection. This association appeared to be largely driven by aortic aneurysm.

5   2018-05-22 10:34:07.893 甘油三酯水平升高和CVD风险升高 (点击量:0)

甘油三酯水平升高是心血管疾病事件的风险因素。 在一项对58,000名年龄在40-65岁,没有心血管疾病(CVD),糖尿病和基线时使用他汀类药物的丹麦人进行的人口研究中,估计了由甘油三酯水平升高导致的风险程度。 在基线甘油三酯水平≥264mg/ dL(3.0mmol / L)的患者中,估计10年内发生主要不良心血管事件(MACE)的风险开始接近具有升高的低密度脂蛋白胆固醇的患者的MACE风险, 达到开始他汀治疗的阈值。 我们目前推荐药物治疗以降低患有胰腺炎风险的患者甘油三酯(甘油三酯> 886 mg / dL [10.0 mmol / L])。 目前还没有关于他汀类药物或其他药物治疗针对甘油三酯水平较低的患者用于预防MACE的研究。

Aims To identify individuals at high risk of atherosclerotic cardiovascular disease (ASCVD), who are not definite statin eligible according to the 2016 European Society of Cardiology/European Atherosclerosis Society (ESC/EAS) guidelines, based on high concentrations of plasma triglycerides.

Methods and results From the Copenhagen General Population Study (2003-2015) 58 547 individuals aged 40-65 and free of ASCVD, diabetes, and statin use at baseline were included. Of these, 14% were definite statin eligible, 7% were not eligible and had triglycerides ≥3.0 mmol/L (264 mg/dL), and 79% were not statin eligible and had triglycerides <3.0 mmol/L (264 mg/dL). During 456 057 person-years of follow-up, 1770 individuals experienced a major adverse cardiovascular event (MACE) and 734 experienced a myocardial infarction (MI). The cumulative incidences of MACE at age 70 were 8.1% (95% confidence interval 7.3-8.9%) and 14.6% (12.6-16.8%) in statin non-eligible individuals with triglycerides<3.0 mmol/L (264 mg/dL) and≥3.0 mmol/L (264 mg/dL), and 16.5% (14.0-19.3%) in statin eligible individuals. Corresponding cumulative incidences of MI were 3.0% (2.7-3.3%), 7.8% (6.4-9.5%), and 7.1% (5.9-8.4%), respectively. The estimated 10-year risks of MACE were 2.8% (2.6-3.0%) and 5.7% (4.9-6.6%) in statin non-eligible individuals with triglycerides<3.0 mmol/L (264 mg/dL) and≥3.0 mmol/L (264 mg/dL), and 7.6% (6.9-8.3%) in statin eligible individuals; the median age in these three groups were 51, 51, and 60 years, respectively. Corresponding risks of MI were 1.0% (0.9-1.1%), 3.0% (2.4-3.7%), and 3.3% (2.8-3.7%), respectively.

Conclusion Statin non-eligible individuals with triglycerides ≥3.0 mmol/L (264 mg/dL) had risk of ASCVD similar to statin eligible individuals, defined according to the 2016 ESC/EAS guidelines. This illustrates an unmet need for primary prevention, calling for expansion of guidelines on statin eligibility, and the potential for placebo-controlled randomized clinical trials in individuals with hypertriglyceridaemia.

6   2018-05-22 10:33:04.82 导管消融治疗伴有心力衰竭的心房颤动 (点击量:0)

对于许多心力衰竭(HF)和心房颤动(AF)患者,我们更倾向于AF管理的速率控制策略。用药物治疗(例如抗心律失常药物)或导管消融(CA)可以实现节律控制。在许多这些患者中支持使用CA的最有力证据来自CASTLE-AF随机试验,该试验将363名有症状阵发性或持续性房颤患者的CA与药物治疗(心率或心律控制)进行比较;纽约心脏协会II,III或IV类HF;左心室射血分数≤35%;失败或不愿意服用抗心律失常药物治疗;和植入式心脏复律除颤器。 CA显着降低了因任何原因造成的主要复合终点或因HF恶化而住院治疗。根据CASTLE-AF的结果,我们现在建议将CA作为适用于所选择的AF和HF患者的适当治疗,因为他们最初尝试抗心律失常疗法是无效的。

BACKGROUND Mortality and morbidity are higher among patients with atrial fibrillation and heart failure than among those with heart failure alone. Catheter ablation for atrial fibrillation has been proposed as a means of improving outcomes among patients with heart failure who are otherwise receiving appropriate treatment.

METHODS We randomly assigned patients with symptomatic paroxysmal or persistent atrial fibrillation who did not have a response toantiarrhythmic drugs, had unacceptable side effects, or were unwilling to take these drugs to undergo either catheter ablation (179 patients) or medical therapy (rate or rhythm control) (184 patients) for atrial fibrillation in addition to guidelines-based therapy for heart failure. All the patients had New York Heart Association class II, III, or IV heart failure, a left ventricular ejection fraction of 35% or less, and an implanted defibrillator. The primary end point was a composite of death from any cause or hospitalization for worsening heart failure.

RESULTS After a median follow-up of 37.8 months, the primary composite end point occurred in significantly fewer patients in the ablation group than in the medical-therapy group (51 patients [28.5%]vs. 82 patients [44.6%]; hazard ratio, 0.62; 95% confidence interval [CI], 0.43 to 0.87; P=0.007). Significantly fewer patients in the ablation group died from any cause (24 [13.4%]vs. 46 [25.0%]; hazard ratio, 0.53; 95% CI, 0.32 to 0.86; P=0.01), were hospitalized for worsening heart failure (37 [20.7%]vs. 66 [35.9%]; hazard ratio, 0.56; 95% CI, 0.37 to 0.83; P=0.004), or died from cardiovascular causes (20 [11.2%]vs. 41 [22.3%]; hazard ratio, 0.49; 95% CI, 0.29 to 0.84; P=0.009).

CONCLUSIONS Catheter ablation for atrial fibrillation in patients with heart failure was associated with a significantly lower rate of a composite end point of death from any cause or hospitalization for worsening heart failure than was medical therapy. (Funded by Biotronik; CASTLE-AF ClinicalTrials.gov number, NCT00643188 .).